Fascinating interactive infographic on international health care spending gap

It’s not news that the US spends far more per person on health care than other high-income countries (and we get less for that spending, but that’s another blog), but an interactive infographic  from the New England Journal of Medicine breaks it down by year and category of spending. Like the best cool graphics, this one carries a lot of interesting content. The US is an outlier in all categories but we have some limited competition for the biggest spender in a few categories, including Canada for public health service spending per person (we are a bit higher). The worst gaps between the US and the rest of the world are in total spending and private insurance spending (no surprise). Most countries spend more on either government or private/out-of-pocket spending (depending on their model) but we are the highest spender on both. The worst trending gap between the US and the rest of the world is in health administration and insurance – we are not only the highest spender but also growing faster than anyone else.  Comparisons are in Purchasing Power Parity (PPP) $ US which controls for the value in goods and services between countries. Graphics like this give hope that we can fix our system – there is clearly enough money being spent.

Advocates meeting with SIM staff

Yesterday’s meeting with advocates called by SIM staff included some good news but more challenges focusing on process over content. Advocates were encouraged that the SIM planners are now interested in getting input from both “real” consumers, especially from under-served populations, and from professional, independent advocates who follow complex policy proposals on behalf of Connecticut consumers. The state’s SIM plan, now finalized, has been criticized for missing the input of critical stakeholders including consumers, and for overstating the minimal input they’ve gotten from independent consumers and advocates. They are now seeking our input on how to implement the plan they have created.

While it is encouraging that the SIM planners are now seeking consumer and advocate input for new committees, there are many challenges.  Advocates pointed out that we have key unanswered questions about the plan, this administration’s intentions, and how it could affect people if implemented. Many advocates have not yet decided whether to support or oppose the state’s application for a federal grant to implement the final SIM plan and the answers to those questions are key. Advocates also await their commitment to, and degree of, genuine consumer involvement in decision-making going forward.

Advocates expressed concerns about SIM planner’s over-attentiveness to the interests of insurers – arguing that consumers should be SIM’s key constituency as both the ultimate payers and ultimate consumers of health care. Advocates made it clear that just listening to advocates is not sufficient – it is critical that they be in decision-making roles and that their input from a variety of means is incorporated into policy. Advocates repeatedly objected to SIM staff plans to have only a few consumers or advocates on each committee, placing them in a minority position. Advocates repeatedly urged SIM to focus less on getting a few “perfect” consumer representatives for their committees, as consumers are not organized into trade associations like other stakeholders, but to open the decision-making process to include and incorporate public input. Advocates gave SIM numerous examples of successful and respectful past policy decision-making models. Advocates urged SIM to ensure that consumers and advocates make up a majority of members of all committees, as in many of those successful models. Advocates also expressed concern that membership would be at the sole discretion of the administration, unlike successful models like the Medicaid Oversight Council whose membership is set in statute. SIM staff resisted that recommendation concerned about sustaining that effort and making enough space for other stakeholders, specifically insurers.

Points I wasn’t given the opportunity to make during the meeting include a concern that these committees, even if they include consumer voices, will still be three levels below where decisions are made on the SIM organizational chart. There is a history in CT of overruling consumer committee input at higher level boards. It is also critical that in any online communications about public input, that consumers be allowed to check whether their input was included or not. Too often policymakers incorrectly believe they have faithfully included consumers’ input but have missed critical points. It is also critical that meetings, especially those with insurers about payment models, be public and transparent rather than private. It is important to note that no advocate asked to be included in secret meetings, we have repeatedly asked that there not be secret meetings. Nothing was decided at the meeting; we await answers to our questions about the plan’s impact on the Medicaid program, CT’s public health system, and promising medical home programs as well as responses to advocates’ strong recommendations for consumer/advocate majority representation on all committees and for transparency and meaningful public input in decision making beyond the committee structure. We look forward to a constructive process that works to foster successful, responsible reforms of CT’s health care system.

More doctors participating in Medicaid

The Hartford Business Journal is reporting on the increase in primary care providers caring for Medicaid consumers. The number of Medicaid primary care providers has more than doubled in the last two years. This is critically important as an estimated 150,000 more state residents will qualify for Medicaid coverage under the ACA. The article credits the recent, but temporary increase, in payment rates, but also cites lasting improvements in administration that could help retain those providers in the program beyond the rate increase.

Book Club -- Predictive Analytics: The Power to Predict Who Will Click, Buy, Lie or Die

A fascinating, sort of scary, book about the power of big data and new analytics to predict human behavior, Predictive Analytics: The Power to Predict Who Will Click, Buy, Lie or Die is the latest addition to the CT Health Policy Project Book Club. In 2012 there was a lot of news about the revelation that Target was using predictive analytics to identify and market to pregnant women and their families, sometimes before they’ve told anyone they are expecting. Since then analytics have gone much further – but it is usually a good thing. Hundreds of examples in the book include predictions of flu trends from Google searches, that retirement reduces life expectancy, and smokers suffer less from repetitive motion disorder. The author goes beyond giving examples to explain in clear language how it’s done and how companies and the government are acting on those predictions.

CT’s final SIM plan: Consumer advocates have questions

Connecticut’s executive branch policymakers have finished the State Innovation Model (SIM) plan to fundamentally transform our state’s fragmented health care system – both how care is delivered by doctors, hospitals and other providers, and how it is paid for. SIM is meant to cover at least three million state residents – Medicare, Medicaid, employer benefits and private insurance – within five years. The SIM results from a federal grant opportunity to develop a plan to restructure our state’s health system. Advocates and others have sent letters and public comments raising concerns about transparency, lack of stakeholder engagement, payment incentives that could create incentives to deny needed care, and new medical home standards.

Based on the final plan, independent advocates representing Connecticut health care consumers have drafted initial questions about the SIM plan and how leaders intend to implement it.

Annapolis CSG/ERC state visit – lots of opinions on the insurance exchange’s problems, Medicare hospital waiver, and SIM

It’s been a fascinating CSG/ERC state capitol visit in Annapolis over the last two days. In meetings with policymakers I’ve heard a range of opinions and emotions on MD’s insurance exchange – from optimism that eventually it will start working to calls to scrap it and revert to the federal exchange. By all accounts, the exchange has not met early expectations that MD would be a national model. Many legislators expressed anger but some are optimistic that the problems will be worked out. Yesterday the legislature passed emergency legislation to cover people who tried to sign up through the state’s high risk pool. Policymakers were very interested in hearing about the experience of other states, Medicaid outreach tools, and eager to get policy tools that control costs while improving quality.

Most are carefully optimistic about Medicare’s approval of MD’s new waiver for all-payer hospital rate setting. Rather than limiting payments by admission, the new plan places a limit on per-capita growth in hospital costs (inpatient and outpatient) at 3.58% for the next five years. The new plan does not change the fundamental entitlement to Medicare and Medicaid and makes no changes to covered benefits. The plan also includes important goals to reduce readmissions and preventable admissions. Legislators had lots of questions about MD’s SIM process and plan expected in the next month.

Ages of CT insurance exchange consumers raising concerns

Board members of Access Health CT are now raising concerns about the age profile of the health insurance exchange’s consumers. Over one third (36%) of people buying insurance there are over age 55, but make up only 12.5% of CT’s total population and 7.7% of the uninsured. In contrast, young adults ages 18 to 34 are under-represented in the exchange – making up 9% of the pool but 21% of the population and 36% of CT’s uninsured. Analysts, and now some board members, are concerned because insurance pools with disproportionately older, and presumably higher cost, populations drive up premiums, as happened with the Charter Oak Plan. Exchange staff and others argued against the concerns, citing federal reinsurance provisions, and waiting to see data on health care utilization and the effect on premiums.

Updated website and expanded reach for comparative effectiveness org – ICER

The Institute for Clinical and Economic Review has a new website with decision aids for consumers and doctors, comparative value analyses of new treatments, and regional roundtables to translate that research into policy. Adding the CA Technology Assessment Forum to their CEPAC work in New England allows millions more people to benefit.

CT health insurance exchange update – enrollees trend older, Anthem billing problems, and good stories of coverage

Customers trying to buy coverage on Access Health CT, our state’s health insurance exchange, from Anthem are having trouble paying their bill to comply with the Affordable Care Act’s January 1^st coverage mandate. Anthem is the most popular choice with 25,000 enrollees so far. Many people have paid their bill but have not been set up on the system causing problems getting care; others are having trouble even paying their bill. Anthem has moved the deadline and set up a complicated work-around system for payments. The Governor and Lieutenant governor planned to meet with Anthem representatives yesterday.

A new federal report finds that 59% of enrollees in CT’s exchange from October through December of last year are older than age 45, higher than the national trend (55%). Only 21% are between ages 18 and 34, compared to 24% nationally. Analysts warn that the exchange needs to attract more young, generally healthier, customers to balance the number of older, generally higher cost, consumers to avoid significant premium increases next year. CT also has more men buying on the exchange than women, in contrast to national trends and more customers are buying without financial supports in CT (32%) than nationally (21%). 26, 468 people (31%) were enrolled in Medicaid.

Beyond the problems, there are many reports of people very happy with the new coverage options – both in the exchange and in Medicaid.

Health equity lectures

The Bioscience CT Health Disparities Institute at UConn Health Center is sponsoring a series of lectures this year on Health Disparities through the lens of Research, Capacity Building, Outreach & Engagement and Policy. The first on January 30th, features Dr. Chau Trinh-Shevrin, on Advancing Health Equity through the Intersection of Social Determinants and Community-Engaged Approaches. Dr. Trinh-Shevrin is an associate professor at the New York University School of Medicine. Her research focuses on understanding, addressing and reducing health disparities in racial and ethnic minority underserved populations. Click here for more on the series and to register for lectures.

Medicaid Council update – very good news on PCMHs

At today’s Medicaid Council meeting we heard an impressive presentation by DSS and CHNCT, Medicaid’s administrative services organization, about the success of person-centered medical homes (PCMHs) in CT’s program. At the end of the year 211,206 Medicaid consumers were being cared for in a PCMH – about one in three CT Medicaid recipients. 65% of all NCQA certified PCMH providers are participating in the Medicaid program. Quality of care in PCMHs is higher than in non-PCMH practices on 9 of 11 measures including adolescent well care rates, diabetes care, and avoiding ED visits. Quality bonuses went out to high performing practices in 2013, with more to come this year, in addition to higher payment rates for all PCMHs. Consumers report better satisfaction with care, better access to specialists and providers more willing to listen. EPSDT rates are higher in PCMHs and practices are largely very satisfied with the support they are getting from the state in achieving and maintaining PCMH certification.

In another presentation, CT Voices for Children reported on continuity of coverage in HUSKY. The most important finding is that continuity is higher in HUSKY Part A (no family costs) than in Part B (with costs for families). In fact, gaps in coverage are more common for children in higher cost bands of HUSKY Part B, suggesting that costs to families are the barrier to staying in the program. This has troubling implications for coverage in CT’s health insurance exchange, where coverage costs can be very high.

Navigators and assisters conference highlights challenges and solutions

Today’s AccessHealthCT conference for outreach workers focused on tools for engaging CT’s uninsured.  In addition to public officials and foundation supporters, the conference included helpful wisdom from navigators in the field. Speakers shared real world challenges (technology, coordination, information gaps), but also solutions and best practices (flyers in energy assistance letters and food bank bags, connecting with community groups). Afternoon workshops focus on outreach to hard-to-reach populations and technical help with the website. But the most interesting part of the conference was informal discussion with on-the-ground assisters who are making a difference in people’s lives despite the challenges.

Paid sick leave not a burden on CT businesses

Two years ago CT became the first state to require businesses with 50 or more employees to cover sick leave for workers. A new survey finds that, despite concerns, the policy has largely been a non-issue for CT businesses. The change in policy had little impact and little to no cost for companies but did improve morale, reduce the spread of illness and improve productivity. 89% of employers already offered sick leave benefits to workers before the law but that rate is up and the number of sick days covered is also up since the law passed. 77% of businesses are now very or somewhat supportive of the policy.

National health spending remains low, enough to drop slightly as percent of GDP

In very good news, CMS actuaries have found that national spending on health care grew only 3.7% in 2012 – the fourth year of low growth and less than the rate of growth in the overall US economy at 4.6%. Per capita health spending grew by only 3%. The low rate caused the share of GDP going to health spending to drop slightly (from 17.3% to 17.2% but going in the right direction). The slower growth was driven by lower growth in prescription drug, nursing home, private health insurance and Medicaid spending. Hospital, physician and clinical services, especially consumer out-of-pocket costs, were up. Slower growth was driven mainly by slowing health care prices, increased availability of generic drugs, and changes in Medicare payments in the ACA. US households remain the largest payer of health care bills, more than private businesses, federal or state and local governments. Health care costs to American households grew by 4.3% in 2012, up from 3.1% the year before. In contrast, government health care cost growth dropped from 3.6% in 2011 to 2.6% in 2012.

CT’s insurance exchange price tag -- $156.3 million

An analysis by the CT Health I-Team finds that setting up our state insurance exchange, AccessHealthCT, is costing $156.3 million – that is $460 for each uninsured state resident. The equivalent of 88 full time workers are involved in the massive undertaking. Most of that money is paying for consultants but salaries consume $14 million and $19 million is being spent on marketing. Most of the funding came in federal grants, but eventually the exchange must support itself – with a 1.35% fee assessed on all CT individual and small group plans, in or outside the exchange.

New, improved Facebook page

(How I spent my winter vacation.) Check out the new, improved (actually finally filled-in) CT Health Policy Project Facebook page – www.facebook.com/cthealthnotes. Like us for updates on CT health trends, policies, proposals, what’s working and what’s not.

January CT Health Policy Webquiz – how will CT’s uninsured fare under the ACA?

Test your knowledge of how CT’s uninsured will fare under the ACA. Take the January CT Health Policy Webquiz.

CT Health reform dashboard – no movement from December

As the ACA’s individual mandate, exchange coverage and dozens of other provisions becomes effective this month, CT has only achieved 28.3% of necessary benchmarks for effective health care reform, according to this month’s CT Health Reform Dashboard. This is exactly where CT was last month. Uncertainty and a lack of protections in the SIM process and unaffordable coverage in the insurance exchange are holding CT back. Medicaid and patient-centered medical homes are once again CT highlights.